Liver Transplantation Society of India Guidelines for the Management of Acute Liver Injury Secondary to Yellow Phosphorus-Containing Rodenticide Poisoning Using the Modified Delphi Technique of Consensus Development

BACKGROUND

Acute liver failure caused by the ingestion of yellow phosphorus-containing rodenticide has been increasing in incidence over the last decade and is a common indication for emergency liver transplantation in Southern and Western India and other countries. Clear guidelines for its management are necessary, given its unpredictable course, potential for rapid deterioration and variation in clinical practice.

METHODS

A modified Delphi approach was used for developing consensus guidelines under the aegis of the Liver Transplantation Society of India. A detailed review of the published literature was performed. Recommendations for three areas of clinical practice, assessment and initial management, intensive care unit (ICU) management and liver transplantation, were developed.

RESULTS

The expert panel consisted of 16 clinicians, 3 nonclinical specialists and 5 senior advisory members from 11 centres. Thirty-one recommendations with regard to criteria for hospital admission and discharge, role of medical therapies, ICU management, evidence for extracorporeal therapies such as renal replacement therapy and therapeutic plasma exchange, early predictors of need for liver transplantation and perioperative care were developed based on published evidence and combined clinical experience.

CONCLUSION

Development of these guidelines should help standardise care for patients with yellow phosphorus poisoning and identify areas for collaborative research.

Pancreatic Tuberculosis: A Puzzle for Physicians. A Rare Case and Review of Literature

Pancreatic Tuberculosis is an uncommon form of extra pulmonary tuberculosis that resembles malignancy of pancreas and serve as a diagnostic challenge for physicians. Conservative management with Anti Tuberculosis Therapy (ATT) will suffice for pancreatic tuberculosis whereas a malignancy may require major surgeries which may lead to significant morbidity. Here, we discuss the case of a female patient who presented with abdominal pain and vomiting and is a known case of chronic calcific pancreatitis. Radiological findings were that of malignancy of the pancreas. Enteroscopy showed pus flowing out from the duodenum. Endoscopic Ultrasound (EUS) guided Fine Needle Aspiration Cytology (FNAC) of the pancreas revealed acid fast bacilli. The patient was treated successfully with ATT. Timely diagnosis of this rare form of extra pulmonary tuberculosis can thus help avoid unwanted resections done for presumed malignancy, for which a high index of suspicion is needed.

Current concepts in the management of acute pancreatitis

Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The "step up" approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.

Acute pancreatitis with disseminated intravascular coagulation

Acute Pancreatitis is seen very frequently. We report a case of acute pancreatitis with a rare complication of disseminated intravascular coagulation (DIC), who recovered completely.